Moral Distress in Neonatology

Pediatrics. 2021 Aug;148(2):e2020031864. doi: 10.1542/peds.2020-031864. Epub 2021 Jul 20.


Background and objectives: To longitudinally examine the nature of moral distress (MoD) experienced by clinicians caring for extremely low gestational age neonates.

Methods: Neonatologists, medical trainees, and nurses were surveyed at regular intervals on their experience of MoD and their preferred level of care in relation to 99 neonates born <28 weeks' gestational age managed from birth until discharge or death in 2 tertiary NICUs. Clinicians reporting significant distress (≥6 of 10 on Wocial's Moral Distress Thermometer) were asked to provide open-ended responses on why they experienced MoD. Descriptive statistics were used to analyze frequency and intensity of MoD across different clinician characteristics. Open-ended responses were analyzed by using mixed methods.

Results: Over 18 months, 4593 of 5332 surveys (86% response rate) were collected. MoD was reported on 687 (15%) survey occasions; 91% of neonates elicited MoD during their hospitalization. In their open-ended answers, clinicians invoked 5 main themes to explain their distress: (1) infant-centered reasons (83%), including illness severity, predicted outcomes, and disproportionate care; (2) management plans (26%); (3) family-centered reasons (19%); (4) parental decision-making (16%); and (5) provider-centered reasons (15%). MoD was strongly associated with the perception of "parents wanting too much." Neonatologists experienced less distress and were more likely than nurses and trainees to align preferred levels of care with family wishes.

Conclusions: The majority of preterm infants will generate some MoD; however, it is rarely shared and of a sustained nature. The main constraint reported by clinicians was "parents wanting too much," leading to disproportionate care.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Attitude of Health Personnel*
  • Female
  • Humans
  • Infant, Extremely Premature
  • Infant, Newborn
  • Longitudinal Studies
  • Male
  • Morals*
  • Neonatal Nursing*
  • Neonatologists / psychology*
  • Neonatology*
  • Nurses, Neonatal / psychology*
  • Psychological Distress*
  • Self Report